Physician Perspectives On Health IT

Quality Metrics

CMS has issued a request for information (RFI) and invited comments on the implementation of the Merit-Based Incentive Payment System (MIPS) as introduced in the MACRA legislation that repealed SGR last April. The legislated "composite performance score" upon which "adjustments" to physician payments will be made under MIPS consists of four categories: Quality, Resource Use, Clinical Practice Improvement Activities and Meaningful Use of CEHRT. Comments are being sought on many topics, including certification of EHRs, technology standards, accountability for data integrity, management of "virtual groups" and, yes, Meaningful Use (MU).

I have three overarching comments:

1. Adversarial relationship with physicians: Right now government programs such as MU and PQRS are generally viewed by physicians as requirements only, not as elements of best practices that lead to quality care. I think it is vital to change this adversarial perception. This will involve a cultural change at CMS. Perhaps the most important tactical change to pursue is moving away from rewarding/penalizing the achievement of specific targets, and moving toward innovative programs that reward practices for making incremental improvements in quality care.

2. Inhibition of Innovation: Physicians support technology innovations developing in the consumer marketplace that have the potential to improve quality of care and lower healthcare costs. While government regulations have the potential to catalyze innovations in the consumer marketplace, they also have the potential to inhibit innovation. Regulations that strive for high-level outcomes are generally more likely to catalyze innovation, while regulations that impose specific limits or require specific actions, mechanisms and processes are more likely to inhibit inhibition. I believe the Meaningful Use regulations have inhibited innovation--EHR vendors have been scrambling to meet specific requirements imposed by the regulations with no evidence that these requirements would result in higher quality of care or lower costs. To change this, we need CMS to mindfully develop government regulations that maintain a high-level focus on the achievement of quality care outcomes while avoiding the development of limitations or specific requirements, methods and processes that discourage innovation.

3. Fair and ethical use of quality metrics for reimbursement: The AMA has published guidelines on the Fair and Ethical Use of Quality Metrics. The guidelines advocate for rewarding physician practices that make incremental improvements in quality care rather than rewarding/penalizing the achievement of specific levels of performance. Although my opposition to the use of quality metrics to impose financial penalties is aligned with these guidelines, I concede that it is difficult for a value-based model of reimbursement to completely avoid penalties. My alternative suggestion is for CMS to incorporate tiered levels of "performance achievement" instead of the "all-or-none" requirements put in place for the MU program. Tiered levels of achievement, with lower levels of achievement designed to avoid certain penalties and higher levels designed to provide additional rewards, will help avoid the "drop-out" rate that the MU program has experienced after Stage 1 as the levels of expected performance were increased. Many physicians just gave up. Even though they could achieve all but one of the requirements, that one requirement eliminated the possibility of receiving any credit.

I would be interested in hearing your thoughts on the implementation of MIPS by CMS.

Many physicians who use an electronic health record (EHR) are having difficulty realizing value in their investment. A recent KLAS survey found that more than one out of every four physician practices are so dissatisfied with their EHR that they are considering replacing it. Although many physician practices have earned a financial award by using an EHR to achieve “meaningful use”, data is lacking on whether or not such efforts actually improve patient outcomes.

I believe, anecdotally, that I practice higher quality medicine when using an EHR. But I am a pediatric emergency medicine physician using a hospital EHR to document patient encounters in a children's hospital's emergency department, not a physician in private practice. On the other hand, my past experience as a a Chief Medical Information Officer (CMIO) and Chief Information Officer (CIO) for my pediatric healthcare system provided opportunities to visit many private physician offices using a variety of ambulatory EHRs and to visit with many EHR vendors. I met many physicians who were happy with their EHRs and see the value. Others I met were unhappy and see no value in their EHR. Perhaps my most eye-opening experience came when I visited with a group of unhappy physicians who were using the same EHR as some happy physicians I had met one week earlier. So what gives?

The answer is simple, but the explanation is complex.

The simple answer is that the value gained from an EHR is dependent on how effectively it is implemented and used. When well-implemented and well-used, an EHR provides clinical and financial value. When poorly-implemented and poorly-used, EHRs detract from patient care and are a financial drain.

The complex explanation might best be explained using examples. So, based on my past visits with physicians who use various EHRs and on other personal research, I have created an outline of what I think are the key factors that allow physicians to gain value from their EHR. I am in the process of writing a series of blogs with case studies to help explain each of these factors. Stay tuned!

I am concerned about the slippery slope of quality metrics that ACOs, private payors and CMS are stepping further down into. My primary concern is that decisions being made by payors on the use of quality metrics are too often resulting in unfair or unethical use of quality metrics. It is critical for community physicians to engage with these entities now to level the slope and establish a more optimal precedent for the future use of quality metrics.

Several years ago I participated in the Texas Medical Association's (TMA) launch of their Health Care Quality Council. One of Council’s primary interests has been the issues inherent to pay-for-performance programs and the use of quality metrics by payors. Some of these issues overlap onto the TMA's ad hoc Health IT Committee that I serve on as well. Physicians in Texas have reported to these committees about unfair and unethical applications of quality metrics such as failure to consider risk adjustments for severity-of-illness or for important socioeconomic factors. Many physicians are concerned that they are getting overwhelmed by requests for different sets of quality metrics from different private payors as well as from CMS. They are also frustrated by the variable, non-standardized methods by which each payor requires the physician's data to be formatted and/or submitted.

Based on my experience with these TMA committees, I have no confidence in the ability of insurance companies or ACOs to develop and use quality metrics in a fair and ethical manner without intimate involvement of working physicians from the community served by the ACOs/payors.

There are guiding principles available regarding the fair and ethical use of quality metrics from the TMA and the AMA. Physicians should actively engage with their ACOs and payors to ensure that these guiding principles are adhered to as quality metrics are developed.

I have consistently advocated for skipping ICD-10 and initiating an unprecedented effort to accelerate the development of ICD-11-CM. Although I still believe this strategy to be the one best aligned with quality care, I fear that the sunken ICD-10 costs are now so large that skipping ICD-10 is unpalatable for most organizations, even for some physicians, and is politically perilous. Since we must do something, I have been thinking more about the proposal to replace ICD-9 with SNOMED in physician practices. Leveraging SNOMED to improve care, lower costs and remove physician practices from the ICD conversion melees should be a serious national conversation at this point.

After several delays CMS has established October 1, 2015 as the new implementation date for the replacement of ICD-9 code sets used by medical coders and billers to report healthcare diagnoses and procedures with ICD-10 codes But another postponement remains a possibility--especially when one considers the unclear reasons for action taken by Congress earlier this year to call off the 2014 implementation. ICD conversion delays are costly to the healthcare industry and action should be taken to address the impediments that increase the risk of such delays. One of the major impediments to address is the adverse impact ICD conversions have on individual physician practices.

So let's jump out of the box of conventional charged impulses propagating across our cerebrums (thinking) to consider how to make ICD-10 optional for physician practices while still achieving our goal of dispensing with obsolete ICD-9 code sets. One alternative is to mandate physicians replace ICD-9 codes sets with SNOMED code sets and require EHRs to incorporate translator technology that converts SNOMED to ICD codes in the background. Since it would not be practicable to expect EHR vendors to incorporate the translator technology into their products by October 1, 2015, there would need to be an interim period where physician practices are exempt from the requirement to use ICD-10 codes sets until their EHR incorporates the translator technology. This alternative mandate allows the ICD-10 conversion to proceed for the rest of the healthcare industry including any physician practices who see value in completing their conversion. This mandate would reduce the current and future adverse impacts that ICD conversions have on physician practices, has higher potential to improve care, is more cost effective, helps EHRs be more user-friendly to physicians and mitigates the risk of further delays to ICD-10 as well as future ICD-X conversions.

I would anticipate a two-year transitional period where the ICD-10 conversion would be optional for physician practices based on an assumption that EHR vendors will need until 2017 to upgrade their products.

Some opposition among physicians is likely to be encountered due to their lack of familiarity with SNOMED as well as questions about how this alternative strategy adds value to patient care. I base that on the responses I heard from some respected colleagues at this weekend's Texas Medical Association meeting. The unfamiliarity issue can be addressed by pointing out that many of us are already using SNOMED, but that we just do not know it. CMS mandates that the problem lists in EHRs use SNOMED codes, so when one selects "Exercise-induced asthma" from a pick list of problems in their certified EHR, they are actually using SNOMED.

More difficult to articulate to physicians is how this proposal to convert from using ICD-9 to SNOMED codes in our EHRs would improve healthcare, how it would improve their work flow and how this is more cost effective for physicians as compared to complying with the current mandate. So I have developed the following bullet list to use when describing this to my colleagues:

Informatics experts are in agreement that ICD-9 is obsolete, and that although ICD-10 has potential to improve healthcare, ICD-11 and SNOMED have higher potential to improve healthcare.

SNOMED, which is interwoven in ICD-11's development, is inherently compatible with ICD-11 and is already required by CMS to be incorporated into certified EHRs for Problem Lists--thus, mandating use of SNOMED is not really new to physicians and will not result in an added cost to physicians

EHRs can be built with technology that automatically converts SNOMED codes into ICD codes--thus, mandating use of SNOMED is agnostic to the version of ICD-X being used; the cost to physicians of using the translating technology is very small as compared to the cost of finishing the conversion to ICD-10 and then converting to ICD-11 in the next 15 years.

After we convert to ICD-10 in 2015, discussions about implementing ICD-11 will ensue; since ICD-10 is over 20 years old and is less sophisticated than ICD-11, it will become apparent rather quickly that we need to convert to ICD-11 as soon as possible in order to improve healthcare (i.e. today's argument about ICD-9)

It takes the U.S. 7-10 years to refine the international version of ICD codes into the U.S. version we use--since the ICD-11 international version is expected to be completed in 2017, the earliest conversion to ICD-11 in the U.S. would be 2024 unless an unprecedented effort to accelerate development took place

In any case, converting to ICD-10 in 2015 will result in two ICD conversions in physician practices over the next 15 years. The proposed alternative strategy to convert physicians one time from ICD-9 to SNOMED results in just one conversion with all future ICD conversions occurring in the background without significant impact on physician practices--thus, mandating the use of SNOMED to replace ICD-9 would be a significant cost savings to physicians.

SNOMED codes have been developed for the purpose of clinical input; ICD codes are developed for important administrative and financial output purposes-- thus, use of SNOMED codes for input will improve physician work flow because SNOMED is more intuitive to use for physicians to describe clinical encounters; this also preserves the use of ICD code sets for the important administrative and financial functions that our healthcare system currently depends on.

I believe that if CMS is going to maintain their mandate to move off of ICD-9, then we should move on to an available coding system that has the most potential to improve healthcare at the lowest cost:

Informatics experts agree that ICD-11 is more sophisticated and has more potential to improve healthcare than ICD-10, but the earliest that a US version of ICD-11 could be available is 2024 unless an unprecedented effort to accelerate development occurs

On the other hand, SNOMED is already incorporated in EHRs and being used by physicians

Thus, I believe the mandate to convert off of ICD-9 is more likely to improve healthcare, improve physician work flow and impose the lowest costs if we make the 2015 conversion to ICD-10 optional for physician practices and mandate physicians start using SNOMED (with the translator technology incorporated in EHRs) in 2017. There will inevitably be tactical challenges involving diverse groups of healthcare stakeholders to work on, but if we remain aligned to the goal of improving quality care, I am confident we will find mutually agreeable solutions.

The idea’s time has come. The U.S. healthcare system needs a national, independent entity empowered by Congress to oversee health IT patient safety. Now.

In today's world a health IT-related patient safety issue that is identified by a physician practice or hospital is investigated and managed in a nontransparent manner by the individual provider and the EHR vendor.

Although the issue may be escalated to a local accountable care organization (ACO) or patient safety organization (PSO) that providers are increasingly becoming associated with, neither the issue nor the results of the investigation are reported to a statewide or national oversight entity. The patient safety data is therefore not collected, aggregated and analyzed at a state or national level. Without such oversight we are missing out on the opportunity to identify known avoidable health IT risks to patient safety and failing to disseminate knowledge on how to manage those risks. For example, if an issue is resolved at the physician practice between the physicians and EHR vendor but is not addressed at other practices that use the same EHR, then patients at those other practices remain at risk.

I have observed EHR vendors tune in to patient safety issues more keenly in the past decade and sometimes make more visible efforts to ensure identified issues are addressed with all customers and not just the ones who report issues. And let's be clear that a majority of EHR-related patient safety risks are related to how an EHR product is being used or implemented by their clients and not due to inherent technical flaws with the vendor's product. Nevertheless, patient safety should be viewed as a shared responsibility between the physicians, their practices or organizations and the health IT vendors. Identifying and managing patient safety risks is done most effectively when all cooperate in a team effort.

In Texas there had been discussions within the Texas Medical Association about establishing a central, statewide EHR patient safety entity to monitor and manage health IT-related patient safety issues. The data would be rolled up from hospitals, physician practices and patient safety organizations across the state for aggregation and analysis. However, it became evident during those discussions that it would be feasible and much more beneficial to establish governance at a national level.

So why does this need to be a new, independent national agency charged by Congress to oversee health IT patient safety?

Today there are many government agencies and private entities that I believe could and should contribute to patient safety surveillance and improvements, but none have the expertise, assets and time that are necessary to coordinate a national effort. In addition to the complexity involved with collecting and analyzing data from hundreds of institutions and PSOs, there are hundreds of unrelated EHR vendor products being used. There is not yet any available registry of health IT products, many of which are subdivided into multiple versions that sometimes vary widely in their available functionality. As a result, I strongly agree with the observations and recommendations described in an article by Singh, Classen and Sittig (J Patient Saf, Dec 2011; 7(4): 169-174) calling for a national patient safety board that is an independent government agency structured similarly to the National Transportation Safety Board. This entity would be charged by Congress to oversee HIT patient safety and coordinate with other agencies who can contribute to improvement in patient safety such as the Office of the National Coordinator, the Federal Drug Administration, the National Institute of Standards and Technology, the Agency for Healthcare Research and Quality, the Center for Medicare and Medicaid Services, the National Quality Forum, local patient safety organizations, local healthcare organizations who collect patient safety data, other local EHR patient safety reporting entities and industrial (EHR and HIT) trade associations. All of these entities need to function in a cooperative fashion in order to effectively identify and manage health IT-related patient safety risks.

The recent health IT report from the Food and Drug Administration Safety Innovation Act (FDASIA Health IT Report) proposes a framework to improve health IT-related safety risks including a proposed National Patient Safety Center.

I am concerned, however, that the proposal does not appear to provide this entity with enough authority to get the job done effectively. A national patient safety entity must have the authority to not only monitor activity and provide learning opportunities for vendors and providers, but also to regulate activities, investigate events, ensure issue resolution and require compliance. I do not see enough "teeth" given to the entity proposed by the FDASIA report.

The primary focus of a national Health IT Patient Safety Center should be on the dedicated surveillance of HIT-related safety risks and to promote learning from identified issues, potential adverse events (“close calls”) and adverse events. But it must also have the authority to effectively manage identified risks and ensure compliance with best practices for health IT patient safety.

I strongly oppose use of quality measures that incentivize or penalize physicians based on their ability to influence patient actions when those actions are beyond reasonable control of physicians or if there is no evidence linking such actions to improvements in patient outcomes. That is why I believe there is a dangerous precedent being set in the Stage 2 electronic health record (EHR) incentive payment rule which will penalize physicians if they fail to influence patient behavior in a manner desired by the Centers for Medicare & Medicaid Services (CMS).

Two of the 17 Stage 2 core objectives hold physicians accountable for ensuring that their patients use technology at home. One measure requires at least 5% of unique patients seen during the reporting period to send a secure message to the physician's practice using the electronic messaging function of the EHR. A second measure requires at least 5% of unique patients seen during the reporting period electronically view, download or transmit their health information.

In order to qualify for Medicare and/or Medicaid EHR incentive payments and avoid financial penalties, physicians must meet all 17 core measures as well as three from a menu of six additional measures. Physicians must also report on nine of a total of 64 specific clinical quality measures. Physicians who fail to do so by 2015 will not only fail to receive annual EHR incentive payments, but also be penalized by CMS through annual payment adjustments.

In the final rule for the Stage 2 EHR Incentive Program CMS responded to public comments on these two new core objectives. CMS argued that physicians are in a unique position to strongly influence the use of technologies by patients "to improve their own care." They did acknowledge a potential barrier of limited broadband internet access that could impact some physician practices and patients. So in the final rule CMS lowered the threshold from 10% to 5% and added an exclusion for practices that are impacted by limited broadband access. CMS summarized their response with, "We believe that this lower threshold, combined with the broadband exclusion detailed in the response, will allow all EPs (eligible physicians) to meet the measure of this objective."

I can agree with CMS that physicians should leverage the influence we have on patient behaviors as part of the care we provide. We certainly are in a unique position to help patients become more engaged in and compliant with their healthcare. I even agree with CMS that the lower thresholds should not be difficult to meet and that it is important for physicians to offer these technologies for patients to use.

My key point of contention with CMS is with the presumption that use of these specific technologies at home allows patients to "improve their own care". If use of these technologies were objectively linked to improved patient outcomes, I could understand the value in financially incentivizing physicians to move patients in that direction. Without such evidence the government's relationship with physicians would be better served through a more tactful approach to promote the use of promising technologies by patients without the strong-armed threat of financial penalties on doctors.

CMS misses the point on this one. Precedent should not be set to penalize physicians based on measures of their ability to engineer desired patient behaviors when those behaviors are not objectively linked to improved patient outcomes. I am not saying that we should not offer these technologies to our patients. I am saying that we should promote their use and then study how that use impacts the quality of care

In today's Health IT News there is an article expressing dissappointment with the recently released proposed rules for Stage 2 of the Electronic Health Record (EHR) Incentive Program. Some alarming viewpoints are evident in this article regarding the collection of data for use by the federal government to improve public health .

The proposed rule for Meaningful Use Stage 2 on page 13702-13703 specifically states that the purpose of Stage 2 Meaningful use is to "“encourage the use of health IT for continuous quality improvement at the point of care and the exchange of information in the most structured format possible”. No where in the rule does it state that the primary purpose of Stage 2 Meaningful Use is to collect data for use by the federal government as is suggested by concerns expressed in this article. Let's keep the data collection cart behind the trailblazing horse so that it does not aimlessly roll down the steepest part of the hill instead of steering toward most beneficial path. Stage 2 objectives draw a sensible roadmap to the next planned destination where we can finally begin realizing the maximum potential value of health IT and EHRs. We currently have the horse trotting around potholes toward the widespread adoption and successful use of EHRs, the development of robust HIE networks, the maturation of EHR product functionalities and an improved understanding of safe EHR usage. If we fail to align Stage 2 activities with Stage 2 goals by taking unplanned shortcuts to collect and use data in hopes of improving care now, I fear the cart will crash and cripple the momentum that Stage 1 has initiated.

Last Thursday the National Coordinator of ONC, Dr. Farzad Mostashari, took my genetics analogy one step further in his keynote speech at the HIMSS12 Annual Conference for health IT in Las Vegas. And I have to admit that he improved upon it. I guess that's why he's in Washington D.C. and I'm not.

Dr. Mostashari warned the 36,000 conference attendees that along with this continued progress there are two other societal trends to align health IT with. He advocated for "twisting health IT to create a triple strand of DNA" with payment reform and patient empowerment.

Health IT, payment reform and patient empowerment. The triple strand of DNA to splice into the healthcare industry. I like that.

Payment reform is seriously needed to align incentives with the provision of quality care in an efficient manner. Right now I am basically paid to "encounter" patients and to do procedures. Although I am personally motivated to provide high quality care, the incentives are oddly there for physicians to "see more" and "do more" rather than to "see it done best". In addition, my documentation is based on meeting reimbursement rules to make sure I get paid rather than being based on communicating a clear picture of my findings and care plan. I absorb the extra time it takes to do both.

Consequently it is no surprise that for decades EHR vendors developed products based on episodic care. Physician's sought out products that would help them document and get paid for patient encounters. Documentation templates and charge capture functionalities were developed to maximize chances for reimbursement.

The potential for EHRs to improve quality and chronic disease management is just now starting to be realized. The ONC's health IT initiatives enacted by CMS under the HITECH portion of the 2009 Recovery Act are providing the push. But as payment reform proceeds, whether it be value-based purchasing, accountable care or some other program, EHR vendors will be incentivized even more to shift development efforts into chronic disease management and clinical decision support that are a basis for improving patient care.

And the third strand of DNA to splice into the healthcare industry, patient empowerment, is indeed an active and growing societal influence. But I will have to blog about that another day...

This video does a good job of describing Meaningful Use, the electronic health record (EHR) incentive program and how the four regional extension centers (RECs) in Texas leverage federal grants to subsidize services for physicians that help them select/implement or upgrade an EHR, and then use their EHR to improve quality of care and meet the Meaningful Use requirements.

The four RECs in Texas currently charge primary care physicians only $300 for consulting services valued at $5,000. These services include:

o Select and implement a certified EHR (or upgrade your current EHR to a certified version)

American Medical Association (AMA) President, Cecil B. Wilson, M.D., said in an AMA Commentary this week, "Physicians should take the time to explore their practice needs, assess their practice's readiness to adopt health IT and select the right system for the practice --and its patients". This is wise advice that I wholeheartedly agree with.

I also agree that the successful adoption and meaningful use of electronic health records (EHRs) impose many new challenges onto physician practices and that overcoming these barriers is especially difficult for physicians in small practices or solo practices that are constrained by limited resources. My only disappointment with Dr. Wilson's message to physicians is that it failed to highlight how Regional Extension Centers (RECs) can be leveraged by physicians to address these issues with EHR adoption and use.

The HITECH portion of the 2009 Reinvestment Act (ARRA) included over $677 million in grant funds to establish RECs across the nation to cover every geographic region. The purpose of each REC is to provide consulting services to physicians that help them overcome many of the described barriers to the adoption and use of EHRs. It is important for physicians to know that the RECs receive federal subsidies specifically based on and proportionate to the number of primary care physicians in solo or small group practices (<10 physicians) that they successfully help adopt, implement and meaningfully use an EHR. In other words, RECs are financially dependent on providing effective health IT consulting services to a segment of physicians who have the greatest need for such services.

In Texas there are four RECs including the North Texas REC (NTREC) for which I volunteer time as Board Chairman. Other Texas physicians volunteer their time to comprise 50% of the governing boards for each of the four RECs. Our goal is to ensure that our RECs are physician-friendly and remained focused on providing high quality services that meet the technology needs of small physician practices in each region. Texas RECs collaborated with each other to create a common business plan that leverages the federal subsidies to charge Texas physicians a token fee of $300 for IT consulting services worth over $5,000.

NTREC will receive 100% of their allotted subsidies if we successfully help 1,500 physicians adopt EHRs and achieve meaningful use. Since last October more than 500 North Texas physicians have enrolled for NTREC services; over half of them have already successfully implemented an EHR and are now working on the achieving meaningful use of their investment.

My hope is that physicians in other states will emulate our efforts by actively engaging in the governance of their region's RECs to ensure that they are physician-centric and remain focused on addressing the unmet needs of the small physician practices.